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HomeMy WebLinkAbout0777 ~ 26?'~162 OH10 DEPARTMENT OF ..ALTH g ~ R`~" D"~' h°' a OIVISION OF VITAL STATISTICS 5"" E~~` Ho" Primary RK. Dix_ No. 4SO4 CERTIFlGATE OF DEATH ~s~xni ~ No. ~`t ' OECEASED-- AME F:.,r .N;~lIli Jwu SEX DATE OF DEATH I.M~.rb, D•~, 1'evJ / i / J 1. ! ~ '2'7l > ' Li 4~4 1.1~~/~ J_ `Il.~/ ' RACE Iobirr, ~ttre, ~rnirat AGE- l~,t UHDER 1 1fEAR UNDER 1 OAY OATE Of {IlTM (.11oub. Dq, ~O NTY OF DEATH i~Jirw. ~tt l~J1y ~ iistbl/~~ f7srn/ M~r. Dni H~rri Mi~. Yr~rl ~ J/ c 1. Yv se. ~7 Se. St. 6. 701+ Gr t/ J t C11Y, YItIAGE OR lOUT10N Of DEATN INSIO! GTl! lIM1T5 MOSr11At O! OTNEt iNSTITYTIOl1-N~ME (/J,wr it rit~rr. sr?t ih~tt o! wrskrl r' ISNsrJ~ 7a M MI ~ ~ ,~a ~ ti, ~ - ~ ,a. ~c c ~ ~ `CGt1 STAiE ~i~TX (Il +Nt :w 11.5.A., ~aae C1TIiEN pf AT COUNTtY MAtf1ED, NEYfR xA!lIEO, SUtllY1NG S~OUSE !Ij vi/t, ~i~t s~iJ~r ~.r~eJ toauuryl . ~ WIDOWEO, OIYORCED f5?triJ~) . r •~O a. ~'J• ~o. ~~-:Gr sc'i~~~'l ~ FI. ~ - ~h'l~i1~ SOCIAI SECUiIiY NUMiER WAS DECEwSED EYE! IN U. S. ACMED iOKESt. J Q (Y~i. s~. ~r wlwrwl fU ~er. ~e ~vr ~r /~ter ~j ier~is~/ U;UAi [ESIOENCE IZa. + 'J - O, IIA. U - wHEtE DECEISEO USUAI OCCit?ATIpN (Gir~ ~iRd o/ ~rer4 d~ae drrisj ~o+t oJ CINO Of t;JSiA:E35 .'3i ~haUSiiT UvED. IF OEATM ~ ~ i;~ GC`uRtED IN s~rkiajlijt, ~vr~ ij rstiaed) -~T/~ • 'y I~b. ' ~i~~iC.G~~ a +NSTiiUTlON, GlVF - t;S,DENCE {Ef0lE tES10ENCE AiE COUNtt C~i1f, YIIIAGE Ot LOGTIOH INSIOE dt1 UMITS STtEET 0 tiUMtEt ACMISSION_ / ~ ) - ~ / ~ - ISIst:/~ya M! ~~JC7 f ~ C~7/~ S` C• G~/ ` tae. O ub .f~ ' ~ C~ ~aa. c, ~ ia.: i : fATMER--NAME Firit Middl~ L~u MOiMER-AtAfQfN HAAIF Fait Mi/J/s Lart ~ 1 S. ~ ~~LI ! L.~ O'~~ ! 6. ~.lC . i ~ . ~ INFORMANT-NAME ~J?Il1~+G ADDeESS (Srrtd ~s R.F.D. ro., sit~ or riUrst, uatt, O 17a. J 17b. ~ W ~//<Y/7i~~~ Q ~ ~ r~ur i. DEATH WAS CA~JSED BY: [ENTEt ONIY ONE GUSE 1ER UNE fOt Id, (bl, AND (d1 N~~XI N i? INiEtVAIT ~ Z 1~. / r ~ . ~ IMMEDIATE CAUSE " ~l.-~ ~u J ~ a r ~ l ~ . s ~ `•v . OUE TO, f~ AS A CO SEQUfN Oia 3 ~ C~~liti~ir, if ~ I ~ c ~ riisi rat riii te lbl ~.r 1 n4 ~ 1 f ~ p in~tJiw t~rt~ I~1. OUE TO. AS A CON QUENCE OF: / ~ ; ~tifi+~ tii rAler- n ~ ~ r,;.s r~rr << P r t /`i y' e , a L~ 9 ~ . ' i ~ ~ARi 11. OiNE! SIGNIfICAN~ CONOIt10NSCorditi~~r soatrif~rti~t t~ Jt~tb hJ a~• ?d~tt1le sartt II~ew iw ~at I(~I AUTO/S~ If YES ratrs ~~liw~ tortil~rt/ i ~ IY~t w~o is Osterri+i~s c~us o! Js~r~ /~V ~~i r T E~' =-~S. d~ w.. ti~' ivs. y ACC~OE?iT, SUICIOf, i10MIpDf DAtF Of tNJUR11 M011! XOW INJUt~ OCQI!!~ /fafe? Wwt 6/ i+~ja~ is ~oJ 1~r 1et fl. itts 18I OR UNOETE~A11NE0 ISHti~~l I.Mo~tb, Di~, Yrr) 20s. I06. lOt• lOd. ~ IN1UR11 AT WOfK •UCE Of IN1UtT .1f fowr. /es, lhsd, f~dlry, IOCATION (ShM n R.f.D. ~o.. sif~ Or filliji. tldt, :i?) ~ ' W IS~tcill 7n ~r N! oQic~ Ifdj.. elr. lSl~cilll C. ~ ' t_. .cert~._~*~~,y-. ~to+tb L'tp Y~w' .tiirRtb L`q !'~c~ MJ.7 ~.15: 5:.~ Riiririf~ i^vIQ/GSIp NO7 DfwiN OCWt[EO At tOt ?l~o~~t •R ff1TSICtAN: I AUVE ON VIEW THE ~ODr (MQVl) !bt ~ft, as. t~ i 1 ATTENOED TME TO Mowtb Dq Y~n AfiEt OEATM. Ibs itsJ ~J N` ~f I~ , k~NVlrl~t, lnt t~ Zla. OECEASEO fROM l/ l 21b. ~ ~ 21c. ~ ~S l' ]II. ~YV ~I~..~ /a , M. ti~ uautfi) sJ~ftl. CE~T~/IG110N-COROnER: O~ tbe lwir o/ ~be eso~i~etiew H~w ~j Jt~t~ Tbr ltsrle~t ry ~rowriusl d~~d o/ ti~ 1~1~ ud/er tbs iwr~uiptio~, iw s~ op~io~, l~rtb Abati Dq Yt~r H~w ~rcrrrel ew tit d~rr rd lr~ te tbt t~rrrNsl rt~ttl. ne. n~. ~n. M. ' 'a ~ CEtT1f1Et-NAME /T~rt ~r lriwll SI ~ Jilli pATE SIGNED ~ f ~ 1 ~ ~ n°. . . _j~" , ~s. ~ L .c..,~.r.. ia~.'"~-- j . r MAIIING ADDRESS-{EtTIf1fR SilEEi Ot R.f.O. HO. GTT Ot YIttA~G STA ZII ~ ~~s. `~d ~.~~,~.J~~! it%- _ "".'~~c~'o ~.~p ~~H/,5 ; ~ ~~t L CtEMATtON DATE NAME Of Cf~?EiEtY O~ fMATORY IOCAi~ /Cit , si/ , n nr~t~) (Satt1 ; ; ~J ~ ~ tas. -:s~-~3 u~. a• t'L 6~c3 c.7ss. /:s~?~.?'~) ~ . ~t~ j = ~ NAME Of EM~AIMER (l!G li0.) fUNERAI DI~EGfOR'S (UC. l10.) ' ~s. l~l~/6~ ~ ~ G' ~ /1 C fUNES/?l fIRA! ANO ADDtES3 ISTlEET NO.~ (GT (ST (Zlf) ~ e ? r ~ n. . % . ' /iCc ~'.GCi / c~!?1d 3%~S~ ~~C. ~ >iG ~ ~'p 5~.~~0 ~a OATE [EC'D ~Y EEGI t' SIGNATURE DAiE ?EUAIT ISSUEO SIGNATY~E +~ER~ON ISSUIHG ?EWIT WfT. NO. - ` ~ 19T ~o ~o. - ,